Michael Goldfarb (Media Relations Manager, MSF-USA) Thank you very much for joining us today. Welcome to this Doctors Without Borders/Médecins Sans Frontières, or MSF, media briefing. My name is Michael Goldfarb. I’m the media relations manager for MSF in New York. Today, MSF released a detailed report on the failure to provide sufficient humanitarian assistance in Syria for the last two years. You can find the report and a press release, along with multimedia materials, at doctorswithoutborders.org.

We have four speakers today. Each will provide a few remarks and then we’ll open up the discussion to Q&A. Our first speaker is Christopher Stokes, general director of MSF in Belgium. He’s actually joining us from London and will provide a broad overview of the medical humanitarian needs in Syria and the overall lack of life-saving assistance in conflict-affected areas.

He’ll be followed by Kassia Queen, also speaking to us from London. She has just returned from Turkey and Syria, where she was working as MSF head of mission. Next will be Audrey Landemann, who has just returned to Paris from Syria, where she was MSF’s project coordinator. Finally, Bruno Jochum, general director of MSF in Switzerland, will speak about the situation for Syrian refugees in Lebanon and Iraq, where he has just visited.

Christopher Stokes (General Director of MSF-Belgium) Hello. Thanks for joining. Médecins Sans Frontières has come out with this report today after two years in the conflict and over a year of operating and working inside of Syria, particularly in opposition controlled areas, and we wanted to share our views on what we’ve been seeing directly: basically, the fact that the situation for Syrian civilians inside of Syria itself is catastrophic, that the aid effort is far too limited and that the health system itself has collapsed inside of Syria. Because the majority of health centers are no longer functioning, many hospitals have been targeted or looted by both sides in the conflict, not only the government but also opposition groups have been responsible for this as well.

And of course as a result, a lot of the doctors and nurses have left the country and many of the senior medical staff are no longer present.

A second issue that’s effected, that’s accelerated, this collapse is that the health on the government side…a lot of the medical supplies were coming from a pharmaceutical industry that was based inside Syria, notably around Aleppo, and a lot of this local, national capacity—production capacity—has been destroyed and also due to the international financial embargo on Syria has made it very difficult for Damascus to even bring in supplies inside the country.

A third reason is also that we have growing insecurity in and around the health structures and hospitals, and we have had several cases of targeting of health structures and hospitals, which has also meant that it’s incredibly dangerous today to be a doctor inside of Syria.

So Médecins Sans Frontières runs three hospitals in a clandestine manner, illegally, without the authorization of Damascus or from neighboring countries, and today what we see on the ground is that it’s not only the war-wounded who need treatment. It’s also the ordinary pathologies—diabetes, pregnant women who need deliveries (MSF has conducted close to 400 deliveries over this period), and general healthcare that’s no longer available. So the ordinary problems of Syrian civilians can quickly turn into a catastrophic problem because there’s no service available.

We’ve seen a dentist perform minor surgery. We’ve seen pharmacists provide healthcare. We’ve seen, in one case, blood transfusions that were not even tested, resulting in the death of the patient. The patients are given the wrong blood type. The most basic level of healthcare is no longer available in vast areas of the country.

What makes this even more upsetting is that the aid response itself has been severely hampered and there has not been any position to replace the collapsing health service, both on the government side and on the opposition side. Clearly, Damascus here holds a very strong element of responsibility. Damascus holds the key to resolving this. Damascus has limited humanitarian action to areas that it controls to a very few, to a very limited number of organizations and exerts a strong measure of control on the aid they distribute, both in terms of location and quantity, etc., thereby limiting access to on the government side.

Damascus also has made it…has not authorized any organization to work in opposition areas, which has meant that there are hardly any international aid organizations working in opposition areas—opposition-controlled areas. Today, Médecins Sans Frontières Frontier is one of the few and we are having to work in extremely difficult conditions, basically crossing the border illegally to work inside of Syria and provide lifesaving assistance. We’ve had to work often not in recognized structures but in private buildings, in homes, in farms, in one case in an underground hospital as well, so this has limited our ability to provide effective healthcare.

So Damascus clearly has a strong responsibility and has to open up and let the free flow of independent, neutral humanitarian assistance, both on their side but also in opposition areas. Damascus and the opposition group should also facilitate cross-line aid convoys because assistance needs to be able to cross the frontlines in Syria today and this is something that’s only happened very occasionally and very rarely and has limited the ability of assistance that is being provided.

There’s a third element as well that needs to be taken into consideration if we’re going to improve the situation: that neighboring countries should facilitate aid rather than oblige aid organizations to work in clandestine conditions, to be able to work in opposition areas and cross the borders, as I have had to do myself and Kassia, who will be speaking afterwards, has had to do as well. And the MSF teams working inside all have to cross, in some cases with supplies carried on their backs, basically because of the difficulty in getting into the country and the fact that neighboring countries are not facilitating the deployment of aid inside.

A fourth element is also that we believe that the United Nations and the aid effort of certainly the UN—United Nations—should not only work on the government side, government-controlled areas, but should also work on both sides of the conflict, both in government-controlled areas but also in opposition-controlled areas. Clearly, Damascus for the moment has given instructions to agencies working from their side of the conflict not to work freely in opposition group areas. This is something that really we think is unacceptable and we are calling on the United Nations to consider working on both sides, even if it means working without the authorization of Damascus.

Damascus holds the key to facilitate aid and has to open up. Clearly, both sides—second point, both sides have to facilitate cross-line operations. Thirdly, neighboring countries should facilitate the aid operation. And fourth, in the meantime, if Damascus doesn’t allow the free flow of assistance on both sides of the conflict, then we believe that the aid response, and particularly from the United Nations side, should be scaled up on the other side of the conflict in opposition areas as well.

All this needs to be done if we hope to have an improved humanitarian response and if we hope to be able to provide better assistance than has been available in the last two years. We have to realize that we’re in the face of a large-scale conflict that today, the aid response is relatively small-scale and certainly not up to the scale that it should be inside of Syria.

Kassia Queen (MSF Head of Mission, Syria) Hi. I’m Kassia Queen and I’m just coming back from the field and I’m just going to go into a little bit of what was a day like in the field hospital where we’re working, and just to say that it went from, you know, a morning where there was improvised explosive device dropped on a market and having, you know, a small ten-year-old boy come into our health facility who needed care because shrapnel had wounded him, and fortunately him being able to access the health center and to be fine and to be able to survive.

And in that same attack or that same dropping of the improvised explosive device, you had an elderly woman who was basically torn in half, who all we could do at that moment was just to give enough pain medication to make her passing as smooth as possible or as painless as possible for her and to provide mental health support for her and her family.

At the same time, three hours later, we would have a delivery of a child and it just shows the vast needs of what’s happening there. So in the area where we’re working, you still have shelling and violence every single day and at the same time you have men, women and children trying to survive living in these villages. And the health care system has collapsed, so whether that’s the mother who needs to go and seek treatment for her, you know, child who has a fever and a cough because it’s cold in wintertime or whether that’s a man who needs his diabetic medication and insulin, they need help and they need someone to provide that healthcare.

And fortunately we’re able to do that in this area but the needs are so much greater and there are so many places that we are unable to reach. We tried to go further from where our field hospital is doing mobile clinics, which is basically filling medication inside a car and going to different locations and doing general consultations because there are many different facilities that are around, but that they only focus on providing care to trauma victims and the day-to-day healthcare that is needed by the people who are still living in Syria is forgotten. And so we’re trying to definitely focus on the broader health care needs that exist because of this collapse of the health system. Thank you.

Audrey Landemann (MSF Project Coordinator, Syria) Good morning. My name is Audrey Landemann and I am project coordinator for Médecins Sans Frontières in Syria. I came back Saturday from the project that is a hospital, an MSF hospital that opened in June 2012, in the north of Syria. The main activity that we have there is of course trauma emergency surgeries where we treat direct victims of the conflict—people wounded with, by gun shot or by explosions, but we also treat indirect victims of the conflict, such as burns because in the area where we work there is a lot of displaced people and these people live in tents with very basic heaters. They—sometimes these heaters, they explode and we get a lot of civilians with face or hand burns, mainly kids. We also have a lot of patients for post-operative care because surgeries that are done, whether in our hospital or in other health structures, they need to have post-operative care, so dressing changes or physiotherapy. And we try to do some healthcare also for medical emergencies, even if this is not the main objective of our hospital. Because there is no other place for people to get treated, we also take care of medical emergencies. Besides that, activities that we ran until last week was a vaccination campaign for children, because with the collapse of the health system in Syria that is now very important; even the possibility to get the routine vaccinations for children is difficult for the people and Médecins Sans Frontières decided to organize a vaccination campaign for children from zero to five years to vaccinate them against measles and poliomyelitis.

As I said, the health system is really not functioning well anymore. Now, the initiative taken by the medicals in Syria is to try to open a few hospitals or advanced medical posts close to the frontlines where they get patients, whether injured people from the conflict or just people seeking medical care. Sometimes these people working in field hospitals in advanced medical posts are not even doctors or nurses, they are just dentists or students in law or in tourism. They try to organize themselves. They contact, for example, Médecins Sans Frontières to get some help so for trainings or for medical material or drugs. We face a deep problem to really be able to support them because first of all it’s very difficult to go to these places, to be able to do the movement to these places that are located in very dangerous areas, so they are the ones who are every day or when they can coming out of their field hospitals and crossing the frontlines sometimes, or at least moving on roads where there are some shellings to come to a Médecins Sans Frontières hospital to get drugs and medical materials or trainings to help them continue their activities.

In the whole, the main needs that are covered are the emergency surgeries; but concerning the whole range of medical care, there are still a lot of needs that are not covered or fully covered. The chronic disease, for example, there is almost nothing to treat chronic disease. One diabetic patient can look for insulin in a lot of places but will not find the insulin or if he finds insulin it will cost him around 25 to 30 dollars for 1 vial of insulin.

People who have cancer get no treatment and don’t know where to go to get their treatment. People are coming also to look for baby milk or flour just to do bread. There are plenty of medical needs that are not covered and that need to be covered, so definitely massive humanitarian aid is needed all over this place.

Hello. I’m Bruno, general director in Geneva, and also coming back from a visit to the Syrian refugee camps in Iraq and also in the Beqaa valley and Tripoli in Lebanon.

Regarding the refugee situation, I would say the paradox is that, unlike inside Syria, there are very few obstacles to assistance, if any. Overall, looking at the policies of the government of Lebanon but also the Kurdish Regional Government in Iraq, it’s an open door policy with refugees who are about to come in sometimes also to work, to have a certain level of access to the health systems. And I would say the paradox in this situation is that the level of assistance versus the accelerating influx of refugees is way below the needs of the population, so it’s essentially an issue of mobilization of means with, in the end, I would say, very, very little excuse for justifying why sometimes, you know, whole lots of families are without assistance.

In Iraq, if we look more precisely at the situation in Domiz camp, it’s— we have about between 700 to 1,000 people coming in on a daily basis. This camp of Domiz is planned for 22,000 people. We’re now probably between 40,000 and 50,000 people living in the camp with a lot of families in waiting areas. A lot of them have now to share tents. There’s a backlog on the water distribution and what’s needed is basically more aid actors and faster responses, all the more since there’s a predictable increase to be expected. We could well be at probably 60-70,000 people by the month of April and possibly many more in the months to come.

When it comes to Lebanon—so, there are no camps, that refugees mainly taking themselves either trying to rent rooms or basically trying to find shelter in buildings under construction, farms, garages and here the issue is mainly the delays between the registration of these refugees and their access to immediate assistance.

So for a long time until quite recently it was taking three to four months to be registered before having full access to assistance. Some policy changes have occurred in the last few weeks, which should help to improve this, but still there is a limitation on the access to chronic disease treatments in the public health system. There are problems linked to hospital admissions in Lebanese public health structures. Knowing that even the most recently arrived refugees with very little have to actually pay part of the admission fees.

So what we’ve been calling for all these last days and weeks, it’s really to measure, you know, the scale of the policy change which is needed. There has been, over 2012, quite a progressive influx month-after-month. It’s tremendously accelerating since autumn and especially since the beginning of the year and there is a need for a fully blown emergency response up to the needs.

People, families who are fleeing a situation of danger and hoping to find a refuge in a neighboring country should be met with the proper help they deserve. That’s in a nutshell.

Goldfarb Okay, thank you, Christopher, Kassia, Audrey and Bruno. We’ll now open up the call for Q&A.

Operator Your first question is from the line of Michael Gordon.

Michael Gordon (The New York Times) What capacity or capability does the Syrian opposition coalition have to provide for humanitarian aid or take care of the people in the areas, liberated areas, in which it’s present?

Goldfarb Christopher or Bruno, do you want to?

Stokes The Syrian opposition—well, let’s say rather more broadly, actually, the most in the absence of any form of large-scale international aid, which is the aid effort we can say on the opposition in terms of access to opposition areas failed. In the absence of this, of a successful aid effort, it’s true that a lot of the heavy lifting is being done by the Syrian diaspora. So different Syrian organizations that have managed to collect funds from abroad, from Syrians living abroad, and have organized limited forms of assistance inside—but again this assistance clearly isn’t enough in terms of the level of need you have inside, but it’s better than nothing.

And it does leave the impression to any Syrians that I spoke to when I was in these areas that they feel that they’ve been abandoned basically and the international community isn’t interested in assisting them.

Gordon Can I follow that up?

Goldfarb Please.

Gordon In the Rome conference that I recently attended, a big theme of that is that the United States and the international community is going to provide assets, funds to the Syrian opposition coalition, specifically through their Cairo office in the hope that it’ll improve governance and programs in the liberated areas they control. So I’m wondering if this organization has any capacity whatsoever to administer these funds to govern areas they control, particularly when it comes to humanitarian and medical needs.

Stokes Yeah, I don’t think we’re...who knows how this is going to turn out. We can’t predict exactly what kind of capacities will be able to be deployed. It’s true as well that this kind of assistance can be of help but there’s also the need for independent aid organizations that are not from Syria to be able to operate because these are the few organization that in theory should be able to cross frontlines and provide assistance on both sides of the conflict and help all the people inside Syria.

We have to remember that it’s a very polarized conflict, so I agree certainly with, in principle, organizing some form of collective response to be able to take on the needs in the opposition areas by the local population is certainly one part of —could be one part of the solution, but you also need to have independent humanitarian aid actors being able to work in this area because there are parts of these areas that will be very hard to access for Syrian groups.

Operator Have a question in queue from Charlene Gubash

Charlene Gubash (NBC News) Right. I’m just trying to ask if you have any statistics about how many people you have been MSF has been treating in the past let’s say month and if you have kind of a breakdown of people you treat for regular chronic, problems or normal medical treatment, trauma patient and that kind of thing and also people fatalities and injured that kind of thing. If you have any statistics at all.

Stokes Yeah, and some of my colleagues complete as well. In the three clandestine hospitals that we’ve set up in the opposition areas so far, we’ve conducted, well, exactly 1,560— so, close to 1,600 surgical interventions and over 20,000 close to 21,000 general consultations, including primary healthcare and consultations, and there’ve also been around three hundred and…well the exact figure is 368, so let’s say close to 400. These numbers were collected up to January and these numbers have been growing since. And, 368 deliveries and we have to remember that initially we established ourselves to treat the victims of the—the direct victims of the conflict, expecting them to be working with, for war wounded, so we set up surgical services but we quickly realized that there was an absence of general healthcare and that’s why we’ve gone increasingly towards maternal/child health and general consultations for the population in the absence of any formal, organized healthcare.

Landemann I just want to complete for the vaccination campaign that Médecins Sans Frontières did over the last two weeks, where we vaccinated more than 3,000 children for poliomyelitis and over 1,600 children for measles.

Stokes Just to say as well that these numbers many sound quite important but actually they’re—it’s pretty insignificant in regard to the level of need, so we have to—we are aware of our the limitations imposed on our action by the constraints working in this environment, without any form of authorization and the current insecurity and the limited aid response generally. I think clearly 2,000 lives were saved by our intervention and this is a significant achievement but it’s actually woefully insignificant in comparison with the level of need.

Operator And the next question is from Paul Raymond

Paul Raymond (McClatchy) Yeah, hi. I’m just wondering if you could give us some idea actually of how much we really know about what’s happening in terms of numbers of IDP [internally displaced people], for example. Given the difficulty of access to most parts of Syria, whether it’s in the government-held areas or whether it’s in the opposition-held areas, how much, what kind of data is actually available and do you have your own estimate of the number of IDPs. And the other thing is, I’m just wondering if you have an analysis of the reasons why the humanitarian response has been so low.

Stokes Yeah, I think when it comes to giving a general overview, for example giving the total number of displaced inside the country, we’re not in a position to do that. I think this is one of the constraints we have. We’re working in pockets inside of Syria. Obviously, we meet a lot of people who give us direct testimony of what’s happening, in addition to what we’re seeing ourselves through our mobile clinics and our hospitals, but we don’t pretend or have a complete overview of what’s happening inside Syria.

Due to the fragmented nature of the conflict, the fact that aid agencies—there are hardly any aid agencies, if any, operating on both sides of the conflict —I don’t think anybody is really in a position to give a complete overview of what’s happening in terms of numbers inside Syria. But, of course, there are estimates coming out through the UN but we are in no position to confirm them.

And as to the reasons why the aid effort has been so, let’s say, insufficient and not up to the level of need, there are several reasons. As I said, Damascus is clearly in a position to hold the keys to this conflict in terms of providing humanitarian assistance. There may not be political solution on the table today but at least we believe that a significant humanitarian effort could be put in place.

Damascus is not allowing the free flow of assistance in areas it controls. One. And it’s not allowing free flow of assistance in opposition areas, through cross-line operations, and both the opposition groups—the different fragmented opposition groups—and the government are very reluctant to allow any cross-frontline assistance which would be needed to reach the most vulnerable.

And the neighboring governments are not doing enough to allow—third reason—to allow aid agencies to be able to operate in cross-border fashion, which is today much, very much needed.

And fourthly, again I think there’s a lack of international resolve to also accept that the UN system should be able to deploy on both sides of the conflict, even if they don’t have the authorization from Damascus. It’s been done before. It was done in Sudan before, as well, where the UN was working on both sides of the conflict—in north and in the south—without the official authorization of Khartoum.

And we think in the absence of authorization from Damascus, they should be looking at this option and providing assistance to both sides as son as possible.

Raymond Thank you.

Landemann And just in addition, for the first question, to give you an example: in the camps with displaced people where usually they try to keep track of the numbers so it goes from a few thousand to almost 20,000 people population is quite dynamic, so they move according to the conflict and the situation in the villages. But also inside the Syrian local population, there are a lot of people—displaced people— living with local families, so we have like, one house was before maybe a family of six people and it’s very often the case now that this same house goes up to 20 to 25 people in the house.

Operator And the next question is from Neil Macfarquhar.

Neil Macfarquhar (The New York Times) Hi, I have two questions, please. One is in reference to the field. I hear what you’re saying in terms of the need far outstrips the capacity in both trauma and standard healthcare, but in talking to some of the Syrian doctors who have set up some of the field hospitals—I think they said there are about seven—they sort of feel like they’ve a bit of a dent in terms of stabilizing trauma patients and being able to provide some care for people, you know, coming to Turkey, and I’m wondering if you can talk about that at all, basically, what the field hospitals are able to do and not do.

And secondly, when you push the UN on “why aren’t you going over to these other places”, I know Christopher just used the Sudan analogy but in a lot of parts of Sudan there was of course—it wasn’t in battle whereas if they say that if we cut off the civilians in Damascus so that we can serve the people in the north, you know. That’s not going to do us much good, that argument about not violating the UN charter. But how do you balance that?

Queen Yeah, I’ll just start. I mean, there’s definitely many fringe Syrian doctors who are operating in makeshift hospitals throughout Syria, reaching to places that we cannot access and they are trying very hard and doing an amazing job so I think, to the best that they can, with resources coming from different organizations or just the diaspora, they are making a huge difference.

That being said, they are limited because they are directly dependent on this aid coming from outside and crossing borders and lines, which is really difficult to make sure that they get all the needed supplies. Without electricity, they need generators. They need fuel. They need medical equipment. And all of this has to cross frontlines, has to cross borders, in able to reach them. So they are doing an amazing job. They are working very hard, but with limited resources.

Stokes Yeah, and I’d like also…I agree with you that the comparison with Sudan is at least valid politically in terms of not asking for authorization but geographically it will be hard to work in these opposition areas. But what you have today is a system whereby the UN—the areas of intervention of the United Nations—are dictated to, by Damascus, so that’s not a completely satisfactory situation at all.

And on the other side, we have to recognize that, for example, MSF has been working in these opposition areas—in these opposition-controlled areas—not that we only want to work there we’ve been requesting from Damascus the authorization to work in government-controlled areas because we’re aware of the needs—that there are very significant needs—on their side as well, but that’s been refused for the moment.

There are very few aid agencies that are able to work on the government side. But we have to recognize that these areas under opposition control are actually growing and the number of people in these areas is also increasing significantly. There are new villages that are now under opposition control. I’m talking here of evolutions in the past days and weeks. So the number of people who are receiving very limited assistance is actually increasing and that’s why we’re saying that the aid effort has to significantly be scaled up in these areas.

Operator And we do have a follow-up from Charlene Gubash.

Charlene Gubash (NBC News) Hi. I was wondering if you could give us any information about how people—are people being effected by malnutrition because they don’t have access to food or diseases related to not having access to water clean water?

Goldfarb Audrey, maybe you can comment on outbreaks of typhoid and leishmaniasis that we’ve responded to.

Landemann Okay, so for my side and for the place where I work, we’ve not been seeing malnutrition cases per se. What I’ve seen, for example, more is little babies who need, for example, who are still on baby milk only and who are quite small compared to what they should be, so they are not malnourished but they are definitely not, let’s say, normal-sized babies.

Concerning typhoid and other outbreaks in the place where I’ve been working: there have not been any outbreaks until now. The outbreak of typhoid has been seen in Deir-az-Zur area, which is in the eastern part of Syria what we’ve providing treatment for in Deir-az-Zur

Queen Yeah. Definitely Syrian doctors did inform MSF about the typhoid outbreak and so we were able to send over 4,000 treatments to Deir-az-Zur and also more that 500 treatments for cutaneous leishmaniasis as well, which are all related to the lack of clean water and unhygienic living conditions that are happening in the country.

Again, please visit doctorswithoutborders.org for the report we issued today and for addition information on Syria. For any follow-up inquiries, you can reach me at Michael.Goldfarb@msf.org. Thank you very much and goodbye.